OBJECTIVE:To explore the different patterns in early-pregnancy mean arterial pressure (MAP) trajectories before 20 weeks of gestation in pregnant women with chronic hypertension, and whether it can stratify risk for adverse perinatal outcomes. METHODS:We conducted a retrospective cohort study of pregnant women with chronic hypertension who were hospitalized at Peking University Third Hospital between January 2018 and November 2024. By longitudinal trajectory clustering of MAP measurements obtained before 20 weeks of gestation, we identified distinct blood pressure trajectory groups. Multivariable regression models were used to evaluate associations with pregnancy outcomes. RESULTS:Two MAP trajectory groups were identified. The low trajectory group started around 95 mmHg (≈130/80 mmHg) and remained below this level for most of gestation, whereas the high trajectory group started around 105 mmHg (≈140/90 mmHg) and remained above 95 mmHg thereafter. After full adjustment, the high trajectory group had higher rates of composite adverse outcomes than the low trajectory group (21.8% vs. 13.6%; adjusted odds ratio [aOR] 1.494, 95% confidence interval [CI]: 1.059-2.106), shorter gestational age at delivery (B - 0.369 weeks, 95% CI: -0.716 to -0.022), and lower neonatal birth weight (B - 106.065 g, 95% CI: -187.118 to -25.012). CONCLUSION:Early-pregnancy MAP trajectory patterns derived from routine measurements before 20 weeks of gestation provide clinically useful risk stratification in pregnancies complicated by chronic hypertension. These findings indicate that active blood pressure management before 20 weeks is associated with improved perinatal outcomes, underscoring the importance of early and active intervention in pregnant women with chronic hypertension.
BACKGROUND:Among women undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), the association between preconception dietary patterns and assisted reproductive outcomes remains unclear. We aimed to estimate the potential changes in assisted reproductive outcomes under hypothetical preconception dietary pattern interventions using the parametric g-formula. METHODS:In this prospective cohort study, 1414 infertile women aged 20 years or older were recruited using convenience sampling during pretreatment evaluation at a tertiary reproductive specialist hospital in Shandong Province between March and September 2024. Women's pretreatment diet was assessed using the simplified 25-item food frequency questionnaire. Six dietary patterns were calculated, including the energy-adjusted dietary inflammatory index (E-DII), Mediterranean diet (MD) score, American Heart Association (AHA) dietary index, Trichopoulou Mediterranean diet (TMD) score, alternate Mediterranean diet (AMED) score, and Dietary Approaches to Stop Hypertension (DASH) score. Outcomes included three categories: laboratory and clinical outcomes, pregnancy outcomes, and neonatal outcomes. Laboratory and clinical outcomes included implantation rate, blastocyst formation rate, good-quality blastocyst formation rate, and live birth rate. Pregnancy outcomes included miscarriage, gestational diabetes (GD), hypertensive disorders of pregnancy (HDPs), and preterm birth. Neonatal outcomes included large for gestational age (LGA), small for gestational age, and abnormal birth weight. Using the parametric g-formula, we simulated interventions increasing dietary scores to moderate adherence (75th percentile), high adherence (90th percentile), and optimal adherence, and estimated risk differences (RDs), risk ratios, and relative changes for these outcomes. RESULTS:Before the simulated intervention, the rates were 17.35% for miscarriage, 34.01% for live birth, 14.10% for GD, 8.55% for HDP, and 23.31% for LGA. Under moderate adherence to the E-DII simulated intervention, the miscarriage risk was significantly lowered (11.41; 95% confidence interval [CI], 9.61-13.77), with an even lower risk under high adherence (8.66; 95% CI, 7.73-10.23) and the lowest risk under the optimal adherence strategy (7.11; 95% CI, 7.02-7.39). The corresponding RDs were -5.94 (95% CI, -8.43 to -3.34), -8.69 (95% CI, -11.34 to -6.05), and -10.24 (95% CI, -12.86 to -7.59), respectively. The E-DII simulated intervention showed consistent favorable patterns for live birth and GD. Under moderate adherence to the MD simulated intervention, the HDP risk was significantly lowered, with a lower risk under high adherence and the lowest risk under the optimal adherence strategy. The simulated HDP risks were 6.49 (95% CI, 2.24-10.53), 5.82 (95% CI, 0.64-10.48), and 4.94 (95% CI, 0.00-8.71), respectively. The corresponding RDs were -2.06 (95% CI, -4.57 to -0.00), -2.73 (95% CI, -6.17 to -0.05), and -3.61 (95% CI, -7.78 to -1.82), respectively. Under moderate adherence to the TMD simulated intervention, the LGA risk was significantly lowered, with a lower risk under high adherence and the lowest risk under the optimal adherence strategy. The simulated LGA risks were 22.12 (95% CI, 16.69-25.51), 21.28 (95% CI, 14.05-24.78), and 19.15 (95% CI, 7.08-23.10), respectively. The corresponding RDs were -1.19 (95% CI, -3.46 to -1.11), -2.03 (95% CI, -6.10 to -1.84), and -4.16 (95% CI, -13.07 to -3.52), respectively. No clear associations were observed for the AHA index, AMED score, or DASH score with the outcomes. CONCLUSIONS:Simulated intervention analyses suggested that lower E-DII, reflecting reduced dietary inflammatory potential, was associated with select reproductive outcomes, particularly lower miscarriage risk and higher live birth under optimal adherence scenarios. Higher adherence to MD and TMD was also associated with lower simulated risks of HDP and LGA, respectively. These findings may help inform future research on preconception dietary optimization among women undergoing IVF/ICSI.
OBJECTIVE:To characterize anti-Müllerian hormone (AMH) recovery after multiagent chemotherapy for high-risk gestational trophoblastic neoplasia (GTN) and evaluate the impact of regimen and hysterectomy. METHODS:This was a retrospective cohort of 68 high-risk GTN patients treated with EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine, n = 39) or FAEV (fluorouracil, actinomycin D, etoposide, and vincristine, n = 29). AMH was measured at baseline, during treatment, and 1 and 6 months after chemotherapy. Generalized estimating equation models assessed associations of regimen and hysterectomy (n = 18) with longitudinal AMH trajectories. Fertility outcomes were collected in uterus-preserving patients. RESULTS:Median AMH was 2.73, 0.04, 0.47, and 1.26 ng/mL at baseline, during treatment, and 1- and 6-month post-chemotherapy, respectively. By 6 months, 73.5% (50/68) recovered to AMH ≥ 1.0 ng/mL. FAEV was associated with higher AMH during treatment and at 1 month versus EMA/CO (geometric mean ratios 2.19 and 2.55; both P < 0.05) and a higher 6-month recovery rate (86.2% vs. 74.4%). Hysterectomy was associated with higher AMH during treatment (geometric mean ratio 2.25; P = 0.018) but not with 6-month AMH. Among 28 uterus-preserving patients actively attempting pregnancy, 20 (71.4%) achieved ≥ 1 live birth; 6-month AMH was higher in those with live birth (median 1.95 vs. 1.08 ng/mL; exploratory P = 0.053). CONCLUSION:Multiagent chemotherapy for high-risk GTN causes profound yet partially reversible ovarian reserve suppression, with recovery continuing through at least 6 months. FAEV may be less acutely gonadotoxic than EMA/CO, and hysterectomy does not appear to compromise longer-term AMH recovery. Six-month AMH may help guide fertility counseling and individualized follow-up.
OBJECTIVE:To compare maternal and neonatal outcomes in women with preterm prelabor rupture of membranes (PPROM) managed expectantly with either ampicillin-erythromycin or an institutional alternative regimen combining ampicillin, ceftriaxone, and clarithromycin. METHODS:This was a retrospective historical cohort study at a tertiary referral center in Cali, Colombia, including women with singleton pregnancies and confirmed PPROM between 24+0 and 34+6 weeks (January 2019-December 2024). Ampicillin-erythromycin was used from 2019 to 2022, and ampicillin-ceftriaxone-clarithromycin from 2023 to 2024. Primary outcomes included maternal infectious morbidity and early-onset neonatal sepsis. Latency was assessed using the restricted mean time to delivery (RMTD) from Kaplan-Meier curves. RESULTS:A total of 136 women were included: 64 received ampicillin-erythromycin and 72 received ampicillin-ceftriaxone-clarithromycin. The alternative regimen was associated with lower rates of clinical chorioamnionitis (16.7% vs. 32.8%; P = 0.044), maternal sepsis (1.4% vs. 14.1%; P = 0.006), postpartum endometritis (1.4% vs. 12.5%; P = 0.013), and early-onset neonatal sepsis (46.5% vs. 66.1%; P = 0.039). Latency was numerically longer but did not reach statistical significance (RMTD difference 1.39 days; 95% confidence interval [CI]: -2.40-5.18; P = 0.471). CONCLUSION:In expectantly managed PPROM before 35 weeks, ampicillin-ceftriaxone-clarithromycin was independently associated with a reduction in clinical chorioamnionitis after multivariable adjustment. The association with early-onset neonatal sepsis was present in analysis but attenuated after adjustment, and should be interpreted as exploratory. Prospective studies are needed to confirm efficacy, safety, antimicrobial resistance implications, and long-term neonatal outcomes.
OBJECTIVE:Estimation of the actual cervix area observed during the colposcopy is a critical step towards accurate diagnosis, as hidden areas may lead to malignancy in the future. In the present study, an automated algorithm was developed that uses a deep learning segmentation model combined with geometric area estimation techniques to evaluate the percentage of the cervix visualized during colposcopy by the clinician in real-time. METHODS:The colposcopy images from 110 patients were examined with standardized Cusco bivalve specula and were manually annotated to train the segmentation model for YOLOv8s-seg training (100 epochs, batch size 16, learning rate 0.001, COCO pretrained weights). After segmentation, four computational methods: Grid-based method, pixel-based method, convex hull-based method, and a hybrid weighted model integrating these three metrics via weighted averaging, were applied to estimate the percentage of cervix visualized. The estimated cervical visualization scores generated by the proposed methods were validated against the expert visualization scores independently by three gynecologists, who provided independent visual assessments as the clinical reference standard. Agreement was evaluated using Pearson correlation (r), coefficient of determination (R2), and P values. RESULTS:The hybrid model demonstrated a higher correlation with the expert consensus with the Pearson's coefficient r = 0.7231, R2 = 0.52288, P < 0.0001, residual sum of squares = 36.34. Individual methods gave a moderate performance with grid-based (r = 0.497, R2 = 0.247), pixel-based (r = 0.503, R2 = 0.253), and convex hull-based (r = 0.108, R2 = 0.012, P = 0.261). Hybrid fusion achieved synergistic improvement over single methods with medians closely matching expert assessment (~85%-90%). CONCLUSION:This automated hybrid approach demonstrated significant correlation with the clinician grading by addressing a combination of key different image quality metrics during colposcopy and proposing an efficient and an empirical tool for real-time estimation of cervix visualization.
Cervical cancer is caused by persistent high-risk human papillomavirus (HR-HPV) infection and remains a major global health burden despite available preventive strategies. Most HR-HPV infections and associated low-grade squamous intraepithelial lesions (LSIL) regress spontaneously, yet increasing commercial promotion of topical therapies targeting HPV clearance has emerged in clinical practice. This FIGO/International Gynecologic Cancer Society (IGCS) Position Statement critically appraises the available evidence on topical treatments for HR-HPV infection and LSIL, and provides evidence-based recommendations for clinical practice and future research. No randomized controlled trial has been adequately designed or powered to evaluate the effect of topical therapies on the prevention of histologically confirmed high-grade squamous intraepithelial lesions (HSIL/CIN3+). Available studies are characterized by small sample sizes, short follow-up periods, heterogeneous populations, inadequate comparators, and reliance on surrogate endpoints of uncertain clinical relevance, including cytological regression, HPV nondetection, and immunohistochemical markers such as p16/Ki-67. Published meta-analyses reporting statistically significant improvements in virological and cytological surrogates are limited by substantial heterogeneity, publication bias, and follow-up periods under 1 year. Product-specific appraisal of Coriolus versicolor-based and silicon dioxide/selenite-based vaginal gels reveal additional methodological concerns, including retrospective trial registration, industry funding, and misinterpretation of findings consistent with the spin phenomenon. In the absence of high-quality evidence demonstrating clinically meaningful benefit, FIGO and IGCS do not endorse the routine clinical use of any currently available topical agent for HR-HPV infection or LSIL. Evidence-based surveillance remains the standard of care. Future research should prioritize rigorous trial design with histologically confirmed HSIL/CIN3+ as the primary endpoint, adequate follow-up of at least 3 years, and appropriate comparators. Clinical management should center on informed shared decision-making and evidence-based counseling, rather than on interventions lacking proven clinical benefit.
Hepatic endometriosis is a rare extrapelvic manifestation that can mimic hepatic neoplasia and, exceptionally, cause hemoperitoneum. We report a 45-year-old nulligravid woman with longstanding deep endometriosis and anticoagulation for cavoiliac deep venous thrombosis who presented with severe right lumbar pain and signs of peritoneal irritation. Computed tomography showed a 127 × 120 × 112 mm heterogeneous subcapsular and parenchymal lesion in hepatic segments VI-VII, with hyperattenuating ascites compatible with hemoperitoneum. Magnetic resonance imaging demonstrated a solid-cystic lesion with T2 hyperintensity, intrinsic T1 hyperintense blood products, and heterogeneous enhancement, together with bilateral hemorrhagic adnexal endometriotic lesions. After temporary interruption of apixaban, vena cava filter placement, and phrenic artery embolization, multidisciplinary surgery evacuated approximately 1.5 L of hemoperitoneum and controlled bleeding from ruptured hepatic endometriotic tissue. Histopathology confirmed hepatic endometriosis. Recognition of hemorrhagic imaging features in the context of deep endometriosis is essential to avoid misclassification as malignancy and guide timely multidisciplinary management.
OBJECTIVE:To evaluate perinatal outcomes in women undergoing cervical cerclage for prevention of preterm birth in Brazilian maternity hospitals. METHODS:This retrospective cohort study included 1364 women with singleton pregnancies who underwent elective or rescue cervical cerclage between December 2003 and November 2025. Permanent cerclages were excluded. Primary outcomes included perinatal results and early (≤7 days) and late (>7 days) cerclage-related complications. Analyses were stratified by type of cerclage and use of vaginal progesterone. RESULTS:Elective cerclage was performed in 986 women and rescue cerclage in 378. Preterm birth was significantly less frequent in the elective group (35.7% vs 47.6%; P < 0.001). Cervical dilatation at the time of procedure influenced outcomes, with a longer latency period between cerclage and delivery when dilatation was <2 cm (21.26 ± 4.8 vs 14.71 ± 4.9 weeks). Early complications were uncommon (0.9% vs 2.9%; P = 0.006), while late complications were more frequent after rescue cerclage (22.5% vs 28.6%; P = 0.019), mainly preterm labor and preterm premature rupture of membranes. Adjuvant vaginal progesterone was not associated with a reduction in cerclage-related complications overall. However, in the rescue cerclage group, progesterone use was associated with higher rates of term birth and live birth, and lower rates of miscarriage and stillbirth. CONCLUSION:Both elective and rescue cerclages performed favorable perinatal outcomes and low rates of early complications. The benefit of adjuvant vaginal micronized progesterone in perinatal outcomes should be considered hypothesis-generating and warrants confirmation in prospective studies. Our findings highlight the importance of early identification of cervical insufficiency and timely intervention to optimize outcomes.
OBJECTIVE:To determine the impact of minor trauma during pregnancy on adverse pregnancy outcome in primiparous women. METHODS:A retrospective cohort study was conducted at a single, tertiary university-affiliated medical center between 2012 and 2023. Primiparous women aged 18 to 45 years who experienced minor trauma (Injury Severity Score ≤ 9) during pregnancy after 28 + 0 weeks of gestation and subsequently delivered at our institution were included. Outcomes were compared with those of women without trauma using 1:1 propensity score matching. Outcomes included preterm delivery, cesarean delivery under general anesthesia, placental abruption, and need for blood transfusion. RESULTS:Of 59 774 primiparous deliveries, 852 (1.4%) experienced minor trauma during pregnancy. After propensity score matching (727 pairs), no individual adverse outcome showed a clinically significant difference between the study and control groups (all standardized mean differences < 0.2). Findings were consistent among subgroups defined by mechanism of injury, gestational age at trauma, and propensity score stratum, and in a multiparous sensitivity analysis. CONCLUSION:Minor trauma during the third trimester of pregnancy in primiparous women was not associated with a clinically significant increase in adverse maternal and perinatal outcomes in this matched cohort. These findings may help reassure patients and clinicians following minor traumatic events during pregnancy, although appropriate clinical evaluation and monitoring remain warranted.
OBJECTIVE:To explore the association between Composite Dietary Antioxidant Index (CDAI) and cervical cancer (CC) among US women. METHODS:In this population-based cross-sectional study, participants were selected from the National Health and Nutrition Examination Survey (2003-2018). CDAI was assessed using dietary antioxidants from a 24-h dietary recall. CC survivors were identified through a questionnaire. The association between CDAI and CC prevalence was determined using weighted logistic regression. Restricted cubic spline (RCS) analysis was performed to evaluate the linear association between CDAI and CC prevalence. Subgroup analysis was performed to explore the robustness and reliability of the results. RESULTS:Among the 1,044 participants included in this analysis, 174 reported a history of CC and 870 were matched controls. Participants with CC were more likely to smoke, be obese, and live alone than those without CC (all P < 0.05). In the fully adjusted weighted logistic regression model, each one-unit increase in CDAI was associated with a 11.4% lower prevalence of CC among all participants (odds ratio [OR], 0.886 [95% confidence interval [CI], 0.819-0.958]; P = 0.003). Participants in the highest CDAI tertile had a 55.8% lower prevalence of CC than those in the lowest tertile (OR, 0.442 [95% CI, 0.245-0.797]; P = 0.007). RCS analysis indicated a linear inverse association between CDAI and the prevalence of CC (P for overall = 0.012; P for nonlinearity = 0.798). Subgroup analysis showed that the association between CDAI and CC was generally consistent among subgroups, with no significant interactions observed (all P for interaction >0.05). CONCLUSION:CDAI was significantly inversely associated with the prevalence of the CC. These findings suggest that dietary antioxidant intake may play a potential role in the prevention of CC. However, further prospective studies are needed to confirm this association and clarify the underlying mechanisms.
OBJECTIVE:Cesarean section (CS) rates have increased substantially in Australia, with particularly high use observed in private maternity care and for pre-labor CS. The aim of the present study was to describe the CS rates and the clinical indications for pre-labor CS in the ORIGINS birth cohort. METHODS:This study analyzed data from the ORIGINS birth cohort, a large birth cohort in Western Australia, including 9473 births occurring at Joondalup Health Campus between 2016 and 2024. Rates of CS and pre-labor CS were compared across study periods (2016-2020 and 2021-2024) and by facility type (public vs. private). Indications for pre-labor CS were described and compared across study periods and facility type. Poisson regression was used to assess the change in CS rates across study periods, adjusted for maternal demographic and pregnancy characteristics. RESULTS:Overall CS rates were 50.4% for the study cohort. They increased from 48.2% in 2016-2020 to 52.3% in 2021-2024 (adjusted risk ratio [aRR] 1.10, 95% confidence interval [CI] 1.06-1.14) and were 46.2% in public facilities and 62.0% in private facilities. Pre-labor CS rates increased from 31.4% to 36.2% (aRR 1.15, 95% CI 1.10-1.23) and were 28.5% in public facilities and 49.1% in private facilities. Previous cesarean section was the most common indication for pre-labor CS and increased in prevalence across study periods (from 50% to 53.2%). Pre-labor CS performed at maternal request also increased (from 10.8% to 15.3%) and was more common in private hospital facilities (public, 10.8%; private, 17.7%). CONCLUSIONS:CS rates in the ORIGINS birth cohort appeared to be higher than in the broader Western Australian birthing population. Pre-labor CS contributed substantially to rising CS rates in this cohort and was particularly common in private settings. Similarly, pre-labor CS performed at maternal request increased over time and was more common in private settings. Identifying the factors driving CS use is increasingly important.
OBJECTIVE:This study determines the contributions of anxiety disorder and anxiolytic pharmacotherapy on perinatal outcomes and examines prescribing trends during pregnancy. METHODS:A retrospective cohort study was conducted at a single tertiary medical center between 2013 and 2024. Women were classified into three groups: no anxiety, unmedicated anxiety, and medicated anxiety. The primary outcome was a composite of preterm birth, Apgar score below 7 at 5 min, or neonatal intensive care unit admission. Secondary outcomes included preeclampsia and prolonged hospital stay. Multivariable models were adjusted for pre-specified maternal and obstetric confounders. RESULTS:Overall, 142 028 singleton deliveries were included: 136563 (96.2%) with no anxiety, 942 (0.7%) with unmedicated anxiety, and 4523 (3.2%) with medicated anxiety. Anxiolytic prescribing nearly doubled from 2.25% in 2013 to 4.13% in 2024 (Cochran-Armitage Z = 13.287, P < 0.001). Both anxiety groups showed significantly higher odds of the composite outcome compared with no anxiety: unmedicated anxiety adjusted odds ratio (aOR) 1.615 (95% confidence interval [CI] 1.227-2.088) and medicated anxiety aOR 1.685 (95% CI 1.491-1.897). Direct comparison of medicated against unmedicated women revealed no significant difference in any outcome. Preeclampsia was the only outcome where medicated women showed significantly lower odds than unmedicated women (aOR 0.674, 95% CI 0.471-0.981). CONCLUSION:Anxiety disorder during pregnancy was associated with adverse perinatal outcomes regardless of pharmacological treatment status. No significant outcome differences were observed between treated and untreated women. However, because anxiety severity, timing and duration of treatment, and medication adherence were unavailable, these findings should not be interpreted as evidence regarding the safety or causal effects of pharmacological treatment.
OBJECTIVE:To investigate the association between maternal hemoglobin concentration and the risk of birth to a small vulnerable newborn (SVN). METHODS:We conducted a cohort analysis of women with moderate or severe anemia enrolled in the World Maternal Antifibrinolytic Trial-2 (WOMAN-2) across Nigeria, Pakistan, Tanzania, and Zambia (August 2019 to September 2023). Maternal hemoglobin concentration at admission for vaginal birth was categorized into six groups (<50, 50-59, 60-69, 70-79, 80-89, and 90-99 g/L). The primary outcome was SVN, defined as a liveborn or stillborn preterm (<37 weeks), low birthweight (<2500 g), or small for gestational age (birth weight below the average [unsexed] 10th-centile INTERGROWTH-21st standard for gestational age). Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs), controlling for potential confounders. RESULTS:Among 14 444 women, the median hemoglobin level was 85 g/L (interquartile range [IQR] 77-91 g/L), and 39.5% (5703/14444) of newborns were classified as SVNs. A strong inverse relationship was observed between maternal hemoglobin and SVN. Compared with women with hemoglobin of 90-99 g/L, aOR values for SVN were 1.06 (95% CI 0.97-1.16) for 80-89 g/L; 1.27 (95% CI 1.15-1.41) for 70-79 g/L; 1.44 (95% CI 1.26-1.64) for 60-69 g/L; 2.00 (95% CI 1.64-2.43) for 50-59 g/L; and 2.51 (95% CI 1.85-3.41) for <50 g/L. Sensitivity analysis, including multiple pregnancies, yielded similar results. CONCLUSIONS:Increasing severity of maternal anemia is associated with a marked increase in the risk of giving birth to SVNs. The disproportionately higher risk observed at lower hemoglobin levels supports prioritization of women with more severe anemia for intensified monitoring and treatment in high-burden settings.
BACKGROUND:Anemia in pregnancy is traditionally attributed to iron deficiency, but emerging evidence highlights the contribution of other trace elements to hematopoiesis and oxidative defense. Limited studies from India have systematically evaluated their multivariate interactions. AIM:This study assesses serum concentrations of eight trace elements in anemic and non-anemic pregnant women and identifies latent clustering patterns using principal component analysis (PCA). METHODS:This hospital-based cross-sectional study enrolled 100 pregnant women (< 14 weeks gestation) at a tertiary care center in Lucknow, India. Serum concentrations of iron (Fe), zinc (Zn), copper (Cu), selenium (Se), magnesium (Mg), manganese (Mn), cobalt (Co), and chromium (Cr) were measured using inductively coupled plasma mass spectrometry. Data were analyzed using independent t-tests, Pearson's correlation, and PCA with exploratory factor analysis. RESULTS:Anemic women had significantly lower serum Fe (43.10 ± 26.47 μg/dL) compared to controls (77.88 ± 37.71 μg/dL, P < 0.001). Hemoglobin correlated positively with Fe (r = +0.590, P < 0.01) and weakly, negatively with Cu (r = -0.201, P < 0.05). PCA revealed four clusters explaining 70.7% of variance: Fe-Zn-Se, Mn-Cr, Mg-Co, and Cu. These clusters suggest synergistic and competitive roles of trace elements in red cell metabolism beyond iron deficiency alone. CONCLUSION:Iron deficiency remains the predominant cause of anemia in pregnancy. However, PCA underscores the collective influence of trace element clusters, highlighting potential secondary modulators of anemia risk. Broader micronutrient-based strategies, alongside iron supplementation, might improve maternal anemia outcomes in India.
BACKGROUND:Prior cesarean delivery (CD) is a leading indication for repeat CD and a key driver of rising cesarean rates in Sub-Saharan Africa. Evidence on associations between prior CD and adverse outcomes in low-resource settings remains limited. OBJECTIVE:We examined the association between one prior CD and adverse maternal and perinatal outcomes and examined current delivery mode as a mediator of this association among women delivering at Mbarara Regional Referral Hospital (MRRH), Uganda. METHODS:We conducted a secondary analysis of four prospective studies at MRRH (2014-2024). The exposure was having one prior CD, and outcomes included composite adverse maternal outcomes (postpartum hemorrhage, infection, blood transfusion, prolonged hospital stay, and others) and composite adverse perinatal outcomes (stillbirth, neonatal death, preterm birth, low birthweight, low Apgar score, and neonatal intensive care unit admission). We compared the odds of adverse outcomes for women with one prior CD to those with none using multivariable logistic regression. Causal mediation analysis was used to assess whether current CD mediated the effect of prior CD on adverse maternal outcomes. RESULTS:Of 2222 women with at least one prior delivery, 611 (27.5%) had one prior CD. Women with one prior CD more often delivered by cesarean (73.7% vs. 26.4%) and experienced more adverse maternal outcomes (24.5% vs. 15.4%, P < 0.001), including prolonged hospital stay (21.6% vs. 12.7%, P < 0.001). Prior CD was associated with increased odds of adverse maternal outcomes (adjusted odds ratio [aOR]: 1.99, 95% confidence interval [CI]: 1.54-2.57), with 88.9% of this effect mediated through current delivery mode (indirect odds ratio [OR]: 1.78, 95% CI: 1.41-2.25; direct OR: 1.09, 95% CI: 0.79-1.51, P = 0.586). Adverse perinatal outcomes (19.1%) did not differ by prior CD status (P = 0.28). HIV-positive serostatus (aOR: 1.29), referral (aOR: 1.69), and low antenatal care (ANC) attendance (aOR: 1.66) independently predicted perinatal outcomes. CONCLUSION:While prior CD was associated with higher odds of poor maternal outcomes due to repeat cesarean, HIV-positive serostatus, facility referral, and low ANC attendance (but not prior CD) independently predicted adverse perinatal outcomes. Individualized delivery planning and improving surgical safety for women with prior CD and strengthened antenatal surveillance are critical to reducing maternal and perinatal morbidity at referral facilities in low-resource settings.
OBJECTIVE:Although sleep disturbances increase during pregnancy, sleepiness does not appear to follow a similar trajectory. Given that the relationship between sleep disturbances and sleepiness during pregnancy is understudied, we examined their associations to determine whether these relationships strengthen with advancing gestation. METHODS:For this prospective longitudinal survey, we enrolled 3808 women, of whom 3286 responded. Sleep disturbances were assessed in early pregnancy, midpregnancy, and late pregnancy and at delivery. Mixed-effects models were constructed with adjustments for age, body mass index, parity, maternal smoking, and depressive symptoms. RESULTS:Sleepiness decreased from early to midpregnancy and increased thereafter, being highest at delivery. In contrast, the proportion of women with insomnia increased from 19.1% in early pregnancy to 59.1% at delivery. The proportion of habitual snorers (three or more times per week) and short sleepers (<7 h per night) increased as pregnancy progressed, whereas the proportion of long sleepers (>9 h per night) remained stable. Significant sleep loss (>2 h) increased particularly at delivery. Greater sleepiness was consistently associated with insomnia symptoms (all P < 0.001), with stronger effect size estimates in late pregnancy. Sleepiness was also associated with habitual snoring from midpregnancy onwards. Short sleep duration and sleep loss were related to greater sleepiness throughout pregnancy (all P < 0.001), but long sleep duration was associated with greater sleepiness only in early pregnancy. CONCLUSION:Sleepiness during pregnancy followed a U-shaped trajectory but was consistently associated with insomnia, short sleep duration, sleep loss, and snoring from midpregnancy onwards. Screening for underlying sleep disturbances among pregnant women reporting sleepiness may provide an opportunity for timely identification and management, potentially improving maternal well-being.
Retroperitoneal ectopic pregnancy (RPEP) is an exceedingly rare form of trophoblastic implantation within the retroperitoneal compartment, posterior to the parietal peritoneum and anatomically separate from the uterus, fallopian tubes, and ovaries. Proximity to major retroperitoneal vessels, including the abdominal aorta and inferior vena cava, creates potential for severe hemorrhage and complex operative management. Three mechanisms compound this risk by delaying diagnosis: transvaginal ultrasonography is physically limited to the true pelvis and cannot visualize supra-pelvic retroperitoneal implantations; persistent classification as pregnancy of unknown location defers extended imaging; and Zone I implantations may mimic acute pancreatitis, renal colic, or gastrointestinal illness, redirecting assessment away from obstetric consideration. This focused narrative review synthesizes published clinical experience of RPEP to identify recurring diagnostic pitfalls, anatomical patterns, and management themes, and to propose a practical framework for institutional use. The literature search encompassed PubMed/MEDLINE, Embase, Scopus, Google Scholar, and reference lists of relevant publications, from database inception to June 2026, using a structured set of RPEP-specific search terms. No meta-analysis was attempted because the evidence consists of case reports and small case series with heterogeneous reporting. Zone I para-aortic and interaortocaval implantation appears to be the most frequently reported anatomical pattern. Systemic methotrexate alone appears unsuitable as routine definitive therapy for high-risk phenotypes - characterized by elevated beta-hCG, embryonic cardiac activity, or major-vessel proximity. Multidisciplinary operative planning is essential in confirmed or probable cases. Based on this synthesis, we propose diagnostic categories for definite, probable, and possible RPEP; a five-zone surgical anatomical classification intended to support operative planning; and a seven-step institutional escalation framework. These proposals are derived exclusively from very low-certainty evidence consisting predominantly of case reports, small case series, and expert anatomical interpretation. They should be regarded as hypothesis-generating frameworks rather than evidence-based recommendations or validated clinical guidance and require prospective evaluation before clinical adoption.
OBJECTIVE:To examine current practices in obstetric-led postnatal debriefing after unexpected intrapartum interventions, including the frequency, timing, and content of postnatal discussions, and to explore women's perspectives on the current standard of care. METHODS:A prospective survey was conducted at a Dublin maternity hospital between February and April 2024. Women who experienced unexpected intrapartum interventions, including emergency cesarean section, operative vaginal delivery, postpartum hemorrhage, obstetric anal sphincter injury, shoulder dystocia, or manual removal of placenta, were recruited prior to hospital discharge. Patient-reported experiences were collected via questionnaire and linked to clinician-documented debriefing data. Findings were compared with a similar cohort studied in 2019. RESULTS:Of 366 women identified in 2024, 290 (79.2%) were included in the analysis. A total of 72.1% of these women had a documented debrief compared to 83.8% in 2019. Debriefing most commonly occurred on postnatal day 1 for both cohorts. Women reported high levels of understanding of their intervention (83.8% in 2024 vs. 89.8% in 2019), opportunity to ask questions (90.7% in 2024 vs. 88.6% in 2019), and satisfaction with explanations provided (91.7% in 2024). Provision of written information leaflets declined between cohorts, and counseling regarding future pregnancy implications, including trial of labor after cesarean, inter-pregnancy interval, and recurrence risks, was inconsistent. CONCLUSION:Obstetric-led postnatal debriefing is common and valued following unexpected intrapartum interventions, when conducted early and by the clinician involved in the birth. While patient satisfaction is high, opportunities remain to improve documentation, patient education and future pregnancy planning.
